This action might not be possible to undo. Are you sure you want to continue?
Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP) Committee on Nursing Practice 2008 Edition
STANDARDS OF NURSING SERVICES
All rights reserved. All works herein are properties of ANSAP and no part of this book may be copied, reproduced or published in any form without the proper consent of the authors and publishers.
This publication is designed to provide nursing administration a guide reference in managing nursing services. It also reflects the ANSAP’s deep commitment in improving the quality of patient care and management of nursing services in the Philippines. The development was actively participated by the Board of Nursing (PRC-BON) and the ANSAP’s Board of Directors and validated by the Chief Nurses/Nursing Directors who are also members of ANSAP. The initial draft was eventually reviewed and discussed by opinion leaders in focus group of experts. The final blueprint was presented to public hearing attended by key stakeholders around the country. This edition contains a complete set of standards presented in two major components namely; the Clinical and Administration management. Each component has five standards, criteria and measurable elements necessary to help organizations educate the staff. This edition is also a cross-reference to corresponding requirements set forth in the Philippines by ANSAP and the international accrediting body like Joint Commission International (JCI). We view that standards are continuously a work in progress. Hence, we welcome any comments and suggestions for improvement.
TABLE OF CONTENTS
Introduction Clinical Services I. Standards on Assessment of Care Standard I. Assessment Process Standard II. II. Assessment Scope and Content
Standards on Care of Patient Standard I. Care Process Standard II. Care Plan Standard III. Implementation of Care Standard IV. Evaluation of Care Standard V. Pain Management Standard VI. Medication Management Standard VII. End-of-Life Care Standard VIII. Patient and Family Rights Standards on Patient and Family Education Standard I. Education Assessment Standard II. Education Plan and Programs Standards on Access and Continuity of Care Standard I. Access to Care Standard II. Emergency Patients Standard III. Admitted Patients or In-Patients Standard IV. Intensive and Specialized Services Standard V. Standard VI. Standard VII. Continuity of Care
Discharge, Out on Pass, Referral and Follow-up
Transfer of Patient
Standards on Nursing Documentation Standard I. Structural Data Standard II. Clinical Data
this designed manual has two components. I. There are seven (7) criteria that guide the nurses regarding the importance of access to care. Administrator of Nursing Services Standard II. This component focuses on defining what the standards are in the clinical setting. These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. Credentialing Standard V. Standards on Access and Continuity of Care. To achieve this. Classified under are two criteria which include the process and scope and content of assessment. Staffing Plan Standard III. care plan. Quality Monitoring. Clinical and Administration and Management. III. Quality Programs Standard III. Professional and Organizational Involvement Standards on Human Resource Management Standard I. Environmental Safety Standard III. Staff Placement Standard VI. Analysis and Implementation INTRODUCTION This manual is designed to assist health organizations or hospitals with the significant standards necessary to deliver quality nursing service to our clients. Utilizing nursing process – there are five identified standards to wit: II. Standards on Care of Patient. Financial Plan and Resource Allocation Standard VI. Hiring and Appointment Standard IV. Selection.• Administration and Management I. Policies and Procedures Development Standard VII. Standards on Governance and Direction Standard I. Communication of Information Standard II. Recruitments. Patient Clinical Record Standard III. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified. Leadership and Staff Education Standard II. Staff Education Standards on Communication Management Standard I. Staff Job Description Standard V. There are seven (7) identified criteria that identify care process. implementation of care and evaluation of care rendered. II. Strategic and Operational Plans Standard V. . Administrative Record Standards on Quality Improvement Standard I. Included also is the medication management and the family rights. IV. Ethico – Moral and Legal Accountabilities Standard VIII. Direction-Setting Standard IV. The first part is Clinical Services. Standards on Assessment of Care. Governance Structure Standard II. Facility Planning Standard II. Governance Responsibility and Accountability Standard III. V. III. Staff Development Standards on Facility Management and Environment Safety Standard I. IV.
IV. Standards on Quality Improvement. . There are seven (7) criteria included. I. Standards on Human Resource Management. This concerns managing the nursing services in the hospital. III. which include documentation of significant data both structure. Standards on Nursing Documentation. This part contains five (5) criteria which help the nursing administrators in placing the right person to do the right job through identification of the job requirements and qualifications. and clinical based on applicable laws and regulations. The second part is the Administration and Management. Three (3) criteria are identified focusing on the patient’s record. administration record and communication of information. professional standards and institutional requirements. Standards on Facility Management and Environmental Safety. II. These focus also on planning.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. There are five (5) standards identified: V. This standard contains three (3) criteria and covers environmental safety Each standard and criteria has identified measurable elements intended to provide clarity to the standards and to help organizations develop their own policies and procedures according to the standards. There are two identified criteria under this component. Standards on Communication Management. This chapter recommends the need for organizational structure which will delineate responsibility. V. It also enables the chief nurses/administrator to develop a specific hospital system which is efficient and effective. It also includes staffing modalities depending on the type of services. Standards on Governance and Direction. accountability and authority of nursing administration. organization and controlling functions of the nursing service administration and their relationship with other services. direction. This standard has three (3) criteria which address the need to institutionalize continuous quality and performance improvement.
Measurable Elements 1. Physical • Neurological assessment • Cardiovascular assessment • Respiratory assessment • Gastrointestinal assessment • Genitourinary assessment • Musculoskeletal assessment • Intergumentary assessment . Standards on Assessment of Care Standard I: Assessment Process The nurse identifies the health care needs of each patient based on an established assessment process and within the prescribed timeframe. Pain is assessed every 4 hours and as necessary as part of the vital signs monitoring).g. Standard II: Assessment Scope & Content The scope and content of nursing assessment are well defined in an institutional policy wherein those elements common to all assessments and any differences with other health disciplines are identified.1. Those responsible for direct patient care inform the patient and family of the assessment outcome and the planned care and treatment regimen and encourage participation of the latter in the decisionmaking about the priority needs to be met. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information.2. There is an evidence of initial and completion of nursing assessment on the health care needs of each patient within the: 1. Those responsible for direct nursing care prioritize patients’ needs based on assessment results.CLINICAL SERVICES I.1st 2 hours of consultation as an outpatient or earlier as indicated by patient’s condition or institutional policy. plan of care. individual needs or according to institutional policies and procedures (e.1st 24 hours of admission as an in-patient or earlier as indicated by the patient’s condition or institutional policy. There is an evidence of patient’s reassessment throughout the care process to determine response to intervention at interval appropriate to patient’s condition. 1. 3.2. 2. 5.1. 4. Measurable Elements 1. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following: 1. Psychological • Knowledge level • Language spoken • Barriers to learning 1.
Pain assessment 1.7.11. relationship) 2. Sexuality – Reproductive Pattern 2.8. needs and risks 1.Preference and idiosyncrasies 184.108.40.206. extended.10. Social • Cultural concerns 1. Age 5. Other pertinent data are collected using the appropriate assessment. Role – Relationship Pattern 2.3.11. Standards on Care of Patient Standard I: Care Process The Nursing Services Department has an established uniform care process across the clinical setting that reflects integration and coordination of care of other health team members particularly to those patients with similar condition.8.5. Health history • Developmental history (for pediatrics) • Family history • Medications taken • Allergies 1. Activity – Exercise Pattern 2.10.Coping – Stress Tolerance Pattern 2.4. Sleep – Rest Pattern 2. Economic factor • Financial barrier 220.127.116.11. Lack of mobility 5. Sensory – Perceptual Pattern 2. Measurable Elements 1. technique and instruments.2. Spiritual • Religion 1.7.• Sensory assessment 1. There is an established screening criteria according to patients’ functional capacity and needs like: 2.5. Assistance with activities of daily living 5. Elimination Pattern 2.3. Cognitive Pattern 2. Vital signs 1.5. Self – Concept Pattern 2.Discharge plan • Place: home.Value – Belief Pattern 3.9.1. There are existing policies and procedures on care process developed by those responsible for governance which include but are not limited on the following: . Discharge plan is evident in the initial assessment of the nurse particularly to those patients when discharge planning is critical as evidenced by the following: 5. 5. Referral for continuity of care as necessary II. Nutritional – Metabolic Pattern 2.3. Nutritional status. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care.4. address. telephone number. skilled care facility • Individual who will accompany the patient home (name. Continuing medical and nursing needs 5. 4.
1. The care plan is updated as appropriate based on the reassessment made. 1.13. alleviation of suffering and restoration of health. prevention of illness. 6. Measurable Elements .7. 1.1. 2. There is an evidence that family and significant others are involved in the planning process. religious and other beliefs of patients. 1.8.g.5. 1. • • • • 3.15.6. The care plan ensures that priorities of care are established. 1. 1. 1. by the nurse based on patient’s initial assessment data within the 1st 24 hours of assessment or earlier. ventilatory equipment) Care of patient on dialysis (hemodialysis. 1. 4. 1. There is an evidence that nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment based on but are not limited on the following: Standard II: Care Plan The nurse caring for patients develops and updates an individualized written care plan in the patient’s record within the prescribed time frame.4. The care plan is documented in the individual patient’s record to promote continuity of care. 1.12.2. 1.1.14.suppressed patients Care of patient in pain Care of patient on nutritional therapy Care of patient receiving blood and blood components Care of patient receiving medications with narrow margin of safety Care of perioperative patient Care of patient with intravenous therapy 1.11. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. Patient participate in planning of care taking into consideration the cultural. 5.3. 1.9.10. Measurable Elements 1. peritoneal dialysis) Care of patients at risk: Neonates • Critically-ill Children • Mentally disadvantaged • Under anesthesia Elderly Disabled Care of comatose patient Care of patient with communicable diseases Care of patient in restraint Care of patient on chemotherapy Care of immune . 1. Standard III: Implementation of Care The nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment for the promotion of health. 1. There is a written care plan on every patient cared of 2. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e.
Patient Bill of Rights 2. Evidence . 2. Standard IV: Evaluation of Care Measurable Elements 1. 4. monitor.1. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. Code of Ethics for Nurses 1. 1. Scope of Nursing Practice as provided by law and all relevant legislations (e. There is evidence that patients receive care according to pain management guidelines. There is an evidence that patient’s responses to interventions are documented. evaluate and manage patients in pain. 3.1. The revision in care plan if any is reflected in the patient record. 2.based practice 1. The Philippine Nursing Act of 2002 or Republic Act 9173) The nurse caring for patients systematically and continuously evaluates the patient’s progress based on the effectiveness of nursing intervention rendered and medical management provided. Standard of Care: • Acute and Critical Care Nursing Practice • Chronic Care Nursing Practice • Cardiovascular Nursing Practice • Perioperative Nursing Practice • Maternal and Child Nursing Practice • Psychiatric Nursing Practice • Emergency Nursing Practice • Renal Nursing Practice • Pediatric Nursing Practice • Oncology Nursing Practice • Geriatric Nursing Practice • Ethical and Legal Nursing Practice • Nursing Standard on Intravenous Therapy • Infection Control Nursing Practice 1. evaluate and manage patients in pain. .4. There is an existing pain management guideline for nurses to appropriately assess. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations.6. Measurable Elements 1. Ten (10) Golden Rules in Drug Administration 1. There is an evidence that evaluation of care and patient outcome occurs within an appropriate time frame after the intervention (nursing or medical) is initiated.3.g.2. monitor.5. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record.
Living will if any.5.10. The patient’s right of self-determination and choices are respected and accommodated. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. Standard VI: Medication Management The Nursing Services Department has established policies. There are written policies. religion and cultural preferences and practices is evident. Preparing 1. Carrying out physician’s medication order 1. Respect for patient’s values. 2. 2. intervention and evaluation. Labeling 1. Pain assessment. Documenting 1. Advance directives Do Not Resuscitate. Monitoring and Storage 1.1.9.Regulated Drugs 1. There are existing education and training programs for nurses on pain management. . curative. Emergency Drugs 1. rules and regulations.6. Measurable Elements 1.2. procedures and guidelines on medication management for symptomatic. In accordance to statutory laws.12. Endorsing (especially high valuable drugs) 1. Administering (10 Golden Rules in Drug Administration) 1. Pastoral services are provided based on the spiritual beliefs of the patient and family.Reporting on • Medication effects and adverse effects • Medication error and near-miss Standard VII: End-of-Life Care The nurse provides an end-of-life care to facilitate a dignified and peaceful closure of life for patients through physiological.8. Transcribing and ordering 1. 1. 4. Assessment. 1. Waiver.3. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. are respected. 1. preventive.1. 2. psychological. procedures and guidelines on medication management which include but are not limited on the following: 18.104.22.168. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment.7. and palliative treatment of patients’ diseases and for safe nursing practice. Measurable Elements 1. Processes to communicate with and evaluate patients and families about pain are evident.3.2. Personal hygiene is rendered based on patient’s need. 1.4.1. are monitored and recorded.3.Medication Recall System (Expired or Outdated Drugs) 1.
5. Respect for patient’s personal values and beliefs 1. physical examination. transport) 1. Respect the confidentiality of patient health information 1. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1.3. Support patient and family rights by participating in the care decision and care process through information of the following: • Medical condition and confirmed diagnosis and the informant • Planned care. spiritual and cultural concerns. children and elderly) 1. vulnerable patients are infants. Protection of patient’s possessions from theft or loss 1.g.1. Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. procedure.2.6. emotional.2. The patient and family are involved in care management and decision.4. There is a written evidence that the nurse assesses the educational needs of each patient and family which include but are not limited on the following: 1.4. 4. treatment. processes and guidelines that respect and support patient and family rights. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. A place is designated for the patient’s family to stay.g. Respect for patient’s need for privacy (e. Protection of patient from physical assault (e. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies.1. clinical interview.3. Measurable Elements 1. Measurable Elements 1. outcome of care. 2. Interventions address patient and family’s psychosocial. Patient’s and family’s educational level . 3. There are written policies. 1.2. Patient’s and family’s beliefs and values 1. III. There is evidence that nurses are knowledgeable and supportive of patient and family rights. during treatment. Standards on Patient and Family Education Standard I: Education Assessment The nurse assesses the educational needs of each patient and family and documents these in his/her patient record.7. Patient’s and family’s literacy 1.3. unanticipated outcome and participation in care decision according to wishes • Informed consent • Refusal or discontinuance of treatment • Withholding life-sustaining treatments • Assessment and management of pain • Compassionate care at the end-of-life • Process on complaints and differences of opinion about patient care • Participation in clinical research • Organ donation and other tissues • Disclosure of information 2.
2. Process for admitting patient or registering out patient 1. When appropriate. Treatment and diagnostic procedures IV.7.5) are available. Managing patient when bed or space or facilities is not available Standard II: Emergency Patients .1. Criteria for admitting patient or registering out patient 1. 5.4. Patient’s willingness to receive information Standard II: Education Plan and Programs The Nursing Services Department has established educational plans and programs that support patient and family participation in care decisions and care processes with the primary objective of rehabilitating the patient back to his/her functional level and optimal health. 6. Safe and effective use of medications and their side effects 4. Rehabilitation techniques 4. Holding area for patient on observation 1. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4.4. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1. it is evident that the patient and family are educated on topics considered high risk to patients: 22.214.171.124.5.1 to 4. methods and mechanism for education is afforded.4. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. Education resources are available and organized in an efficient and effective manner.6.2. The appropriate structure.5. Safe and effective use of medical equipment 4. Pain management 4. adequate time and communication skills to do so. Patient’s and family’s language 1. Clinical services available 1. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. Patient’s and family’s motivations and emotional barriers 1. Measurable Elements 1. 3. Patient’s physical and cognitive limitation 1.5. Triage or screening • There is evidence that triaging or screening is initiated at the point of 1st contact with the patient 1. There is an evidence that nurses who provide education have the subject knowledge.6.6. 4.3. Preventing interactions between prescribed medications and other medications (over the counter) and food 4. Measurable Elements 1.2.
3. . There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. curative. There is an evidence that staff who responded to emergency patients underwent the necessary training. curative. It is evident that patients admitted and or transferred to intensive and specialized areas/units meet the established criteria and are documented in the patient record.1. Proposed plan of care 2. Measurable Elements 1. 3. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. There is an evidence that nurse actively participated in providing relevant information to patient and family during the admission process which includes but are not limited on the following: 2. Sufficient information to make knowledgeable decision and 2. 2. There is an evidence that nurse screening assessment focuses on preventive. Measurable Elements 1. cultural. There is an evidence that patients with immediate needs/care are assessed. physical.5. the Nursing Services Department has established policies and processes on patient continuity of care aligned with those of the organization and coordinated among other health professionals. It is evident that criteria is physiologic-based and developed by appropriate individuals. to access and in the delivery of care Standard IV: Intensive and Specialized Services The Nursing Services Department has established entry/ or transfer criteria for patients that need intensive and specialized services to meet special patient needs congruent with those of the organization. rehabilitative and palliative services as well as other relevant information are assessed and prioritized based on his/her health condition at the time of admission in the health care facility. Limit or overcome barriers such as language. 2. rehabilitative and palliative services and prioritizes these according to the patient’s health condition.2. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. 4. Measurable Elements 1. Expected outcome of care 2. Standard V: Continuity of Care In diverse health care setting.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. 2.4. Expected cost of care 2. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs.
Standard VII: Transfer of Patient The Nursing Services Department has established policies. Follow-up instruction in an understandable form and manner • Activity • Diet • Next medical consultation • Urgent care indicators 6.5. 6. 4. Continuity of care and coordination of services are evident throughout all phases of care.6. Significant physical and other findings 6.4. Nursing ward services to diagnostic services 1. Other health care settings 2. 3. 5. There are criteria that determine patients readiness to be discharged. Nursing ward services to intensive or special services 1.1. 2. Medications and treatments 6. There is a process on out on pass patients for a defined period of time. out on pass. Nursing ward services to surgical and nonsurgical services 1. out on pass. There are written policies.7. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge. There is a referral system of patients for transfer to other organization. procedures and guidelines regarding the transfer of patient within and outside of the organization. and health professionals in the community.Measurable Elements 1. The patient’s discharge summary is prepared by qualified individuals recognized by the organization.7.6.5. Standard VI: Discharge. referral and follow-up congruent with those of the organization.9. Referral for support services to either health care providers. procedures and guidelines on patient’s discharge. Measurable Elements 1. Diagnostic and therapeutic procedures performed 6. 3.4.2. Out on Pass. Significant diagnosis and co-morbidities 6. During all phases of care. referral and follow-up congruent with those of the organization. Out patient care programs 1. Condition of patient at the time of discharge 6.3. Reason for admission 6.3. Emergency services to nursing ward admission 1.1. Between nursing units or clinical departments 1.2.8. identified as responsible for patient care and documented in the patient record. health organizations or agency. Medications to be taken at home 6. there is a qualified individual. The written policies and processes on patient continuity of care are evident and implemented throughout all phases of patient care particularly but are not limited in the following services: 1. A copy of patient’s discharge summary is placed in the patient record and another copy is given to the patient which include but are not limited on the following: 6. .
Religion 1.2.6. interventions (medical and nursing) and continuous care rendered are written. 2. civil status 1. 2.8.2. Language spoken 1.3. wheelchair. The guidelines and procedures include but are not limited on the following: 2. Transfer is based on the patient’s needs for continuity of care. Registration number and or Admission number 1.1.2. 2. Situation when transfer is not possible is stated.1. Transfer of responsibility to another health provider or health care setting is evident.4. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1.3. Patient’s transfer is documented. Attending physician and referring physician. V.5. Measurable Elements The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. age. professional standards and institutional requirements.126.96.36.199. 188.8.131.52. if any 1. There is relevant/essential. Advance directive 1.2.Measurable Elements 1. transferring hospital. There is an accurate and complete documentation of patients’ structural data in all nursing and 1. Admitted via: ambulatory.6. procedure and guidelines on transfer of patient within and outside of the organization. Measurable Elements 1.4. Safe and quality medical transport services within and outside of the organization are provided. accurate and complete nursing documentation of patients’ clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following: 1. Admitted from: home. 2. care facility 1.1. Date and time of admission and discharge 1.5. stretcher 1. Responsible health care provider during the patient’s transfer is identified. 2. Formal and informal arrangements are apparent. 2. Health Care Insurance Standard II: Clinical Data The nurse documents essential clinical data of each patient accurately and completely based on individualized nursing care plan from admission to discharge in health care facility. Mode of admission/transport/discharge 1. Health history . Summary of patient’s clinical condition. gender. Patient’s addressograph – name. 2. Physical examination (head-to-toe) 1. There is a written policy.
4. Measurable Elements 1.3. social. The Nursing Services governance structure and processes support professional communication. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement. 1. 1. responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility. 3.10.1. Standard II: Governance Accountability Responsibility and . Psychological.6.5. 1. spiritual and economic evaluation Actual and potential health problems and needs Diagnostic and therapeutic interventions Pharmacological management Nursing interventions Health teachings – patient and family Patients’ response and outcome Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I. 2. 1. 4. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. authority. 1. The Nursing Services governance structure is described in written documents with the approval of proper authority.7.8. clinical planning and services and policy development.9. 1. 1.
The governance responsibility and accountability are described in organization’s by-laws. Measurable Elements 1. action plan/activities. 2. Those responsible for the Nursing Services Department governance. mission. interpreted and operationalized. measurable.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. 2. attainable. philosophy. reviewed. managers. Measurable Elements 1. There is a written document that describes how the performances of the governing entity are appraised by specific criteria. Standard IV: Strategic & Operational Plans The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. 4. resources required and contingencies. Standard V: Financial Plan & Resource Allocation The Nursing Services Department has financial plan and allocation of resources required to meet its goals and sustain its operation. mission. 3. Measurable Elements 1. 2. core values and quality objectives congruent with that of the institution and the Nursing profession. . Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. primarily sets its direction by formulating its vision. Measurable Elements 1. reliable. updated. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. timeframe. The vision. 3. Those responsible for governance have established current financial plans and allocation of resources based on the needs of the Nursing Services Department. core values and quality objectives congruent with that of the institution and the Nursing profession. ethical and recorded). time bound. Standard III: Direction-Setting The Nursing Services Department has an established vision. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. job description and other similar documents. widely disseminated. Those responsible for governance appoint the Nursing Services Administrator. philosophy and core values are written (specific. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. Those in the managerial and clinical levels translate the overall Nursing Services Department’ strategic and management plans into action which include: the management of patient care. philosophy. nursing manpower and unit operation of responsibility areas. mission.
3. 2. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices. The medical supplies. professional and interprofessional relationships and other related endeavors. Measurable Elements 1. Measurable Elements 1. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care.2. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. regulations and standards. 3. 4. Those responsible for governance ensure compliance with the applicable statutory laws. rules and regulations. . Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. and conforms with the applicable statutory laws. Each Nursing Unit has an individual budget plan periodically monitored for variances. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Standard Involvement VIII: Professional & Organizational The administrator of the Nursing Services Department actively participates and collaborates with leaders within the organization and professional associations for continuous quality improvement of nursing services. An updated manual of Nursing Services policies and procedures exists and provides clear directive for nursing personnel at different levels on the scope and limitations of their functions and responsibilities to patient care. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. Measurable Elements 1. 2. Standard VII: Ethico – Moral & Legal Accountabilities The Nursing Services Department has an established framework for ethico-moral and legal management to support the ethical decision-making in the clinical areas. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration.
1. Be a registered nurse in the Philippines. 184.108.40.206.3. A person occupying the position of chief nurse of director of nursing service shall.1. those who have a master’s degree in public health/community health nursing shall be given priority.4. with a least nine (9) units in management and administration courses at the graduate level. 2. A master’s degree major in nursing. Possess a degree of bachelor of Science in Nursing. There are presence of evidences that the Nursing Service Administrator is qualified to the position based on RA 9173 and other criteria set by the organization/institution such as: 1. Those responsible for the overall administration and management of Nursing Services is a member of the top Executive/Management Committee who participates in their regular meetings and provides advice and recommendations in relation to nursing practice.1).3) of the above.1.4. in addition to the foregoing qualifications. possess: 1.1. experience and demonstrable proven ability in nursing practice and administration. Standards on Human Resource Management Standard I: Administrator of Nursing Services The Nursing Services Department is administered by a qualified nursing administrator pertinent to licensure.2. fully responsible and accountable for the operation of the entire Nursing Services of the organization/institution.2.). Standard II: Staffing Plan .1.1. That for chief nurses in the public health agencies. and 1.1.3. the maximum academic qualifications and experiences for a chief nurse shall be as specified in subsections (1. 1.1. (1. priority shall be given to those who have finished a master’s degree in nursing and the completion of the General Staff Course (GSC).1. 1. and Be a member of good standing of the accredited professional organization of nurses. 1. Measurable Elements 1.1 Qualifications of Nursing Service Administrators: A person occupying supervisory or managerial positions requiring knowledge of nursing must: 1. At least five (5) years of experience in a supervisory or management position in nursing.1. Have at least two (2) years experience in general nursing service administration. 1. That for primary hospitals. and (1. That for chief nurses in military hospitals. appropriate education.2. II.5.1.
3.The Nursing Services Department has a staffing plan that identify the number. reviewed and updated on an ongoing basis. Standard V: Staff Placement The Nursing Services Department has defined criteria and processes to ensure the clinical staff knowledge and skills are consistent with the patients’ needs. verifying and evaluating the nursing staff credentials. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. There are legitimate and legitimized processes to recruit. hire and appoint nursing services personnel and are uniformly implemented. training. select. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. skills and experience) of Nursing Services staff. Those responsible for Nursing Services governance develop an effective process for gathering. type and desired qualification of nursing services staff which is written. hiring. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. . work experience) and other pertinent requirements. education. education. level and modality of care. Measurable Elements 1. type of services. 3. reviewed and updated on an ongoing basis. Measurable Elements 1. patients’ mix. 2. selection. Standard III: Recruitment. hiring and appointment are based on institutional. Staff recruitment. Selection. 2. hiring. There is evidence of standardized procedure to gather the credentials of all nursing staff. Measurable Elements 1. Those responsible for Nursing Services governance develop a staffing plan that identify the number. type and desired qualification (education. 2. staff and skills mix and other factors affecting the projection of staffing needs. selection. verifying and evaluating the nursing staff credentials (licensure. training and work experiences of nursing personnel are documented and updated. patients’ needs and applicant qualification. selection. The licensure. Those responsible for Nursing Services governance consider the organization’s mission. 3. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures.
Those responsible for Nursing Services governance develop and define the criteria (core competencies) and processes to match the clinical staff knowledge and skills with the patients’ needs. Career counseling and career advancement/ladder. 2. which specifies duties and responsibilities based on established standards of performance. Measurable Elements 1. Continuing education. training and opportunities for professional advancement of staff member to enhance their knowledge and skills. Accountability 1. c. d. There is evidence of staff development programs for all nursing personnel throughout the year which include: a. 3.2. b. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary.4. There is a written Job Description for each position classification of Nursing Services personnel which specifies: 1. 3. Functional relationship 1. staff and property. available resources and staff competencies.1. Duties and responsibilities 1. Resources are available to implement the staff development program such as: . Safety program to protect the patient. to the organization department/unit to which they are assigned as well as their specific job responsibilities. There are written core competencies required for every job position in the Nursing Services organization to ensure that the staff skills are consistent with the patients’ needs.3. Staff placement/assignment is based on patient needs.2. Measurable Elements 1. Orientation program for newly hired and promoted staff. Qualification and experience required Standard VII: Staff Development The Nursing Services Department has an established staff development program for all nursing personnel to encourage and promote continuing personal and professional growth and development. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses. 2. Measurable Elements 1.
5. Standards on Facility Management & Environment Safety Standard I: Facility Planning For efficient and effective delivery of nursing care and services. • Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use.6. Those responsible for governance comply with relevant laws. Hazardous Materials and Waste • There is a current list of hazardous materials and waste to safely control them (e. There is a written and up-to-date plan.3. tampering. plan and budget for upgrading or replacing key components based on facility inspection findings. List of attendees/participants III. Program design and content 5. functional and supportive facility to patients and their families. Standard II: Environmental Safety The Nursing Services Department actively participates in the planning.4.2. Objectives of the program 5. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement.3. chemicals.1. 5. Educational resources 3. Clinical and clerical staff 3. chemotherapeutic agents. staff and others.g.2. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1. Safety and Security • There is an existing provision for the identification of patient and their families. 2. Audiovisual equipment 3. Measurable Elements 1. Space and facilities 3. the Nursing Services Department provides a safe.2. visitors. . Title of the program 5. 3. staff and visitors aligned with that of the organization’s master plan. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment. Effectiveness of the program 5. Records of staff development program are maintained which include: 5.3. Resource speakers 4. Policies and procedures on continuing education staff attendance to staff development programs are evident.1. Evaluation of the attendees 5.4. Those responsible for governance. radio-active materials and waste. Measurable Elements 1. Medication Room) 1. regulations and other requirements that are applicable.5.1. destruction or loss.g. (e.
inventory and disposal of hazardous materials and waste. • There are infection surveillance. epidemics.4. seven (7) days a week. institutional emergencies. 1. Emergencies • An emergency management plan and processes are evident to likely community/ 1. Measurable Elements . preventive maintenance. • Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. • Monitoring of utilities is evident for purposes of planning and improvement. • A written emergency processes is in place in the event of water interruption or contamination. exposures and other accidents related to hazardous materials and wastes.6.7. electrical failure or interruption and medical gases unavailability. • There is evidence that the nursing staff is provided with education on infection control practices. infectious waste). Documentation and reporting system are in place for investigation of spills. 1. Infection Control • There is evidence that policies. and medical gases are available 24 hours a day. There is an existing written processes on handing.3. Medical Equipment • There is an updated policy and processes on medical equipment procurement. prevention and control programs to identify and reduce the risks of acquiring and transmitting infections among patients and nursing staff. Fire Safety • There is an evidence that fire safety plan and program of the organization/institution is implemented in a continuous and comprehensive manner to all patient care and staff work areas. and recall system. Utilities • Potable water. procedures and guidelines on infection control are implemented. labeling. 1. and disasters. Standard III: Staff Education The Nursing Services Department ensures education and training of staff to effectively carry out their roles in creating a safe and sound patient and staff environment. regular inspection. use. 1.• • hazardous gases and vapors. inventory. storage.5. electrical power.
4. nursing personnel and other health professionals throughout the organization. Directives. Vision. Standards on Communication Management Standard I: Communication of Information The Nursing Services Department has efficient and effective system of communication with the community. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. 2.3. Circular. There is an evidence of staff education and training on facility management and environmental safety programs. Confidentiality of record 1.3. Patients and Families • Patient health condition • Care provided to patient • Patient’s response to care • Patient/nursing care services available • Alternative sources of care and services • Process to access care • Educational materials and methods in an understandable format and language 1. Standards • Memorandum. Community • Patient/nursing care services • Health programs • Process to access care 1. Activities 1.1. Measurable Elements 1. There are written policies.2. procedures. and guidelines on patient clinical record which include but are not limited on the following: 1. Procedures. procedures and guidelines on patient clinical record.1. Guidelines. Clinical record for every patient assessed or treated. Measurable Elements 1. Mission. There is an evidence of staff training to operate medical equipment appropriate to their job description. VI. Security of record . in-patient or out-patient 1. Other Health Professionals (clinical and nonclinical staff) • Patient care and response to care (referral) • Patient clinical data (diagnostic examinations and therapeutic procedures) • Circular Standard II: Patient Clinical Record The Nursing Services Department has established policies.2. to patients and their families. There is an evidence that the staff can describe and demonstrate their role in the aforementioned safety programs.1. 3. Core Values • Policies. Nursing Personnel • Nursing endorsement in between work shifts • Nursing documentation • Referral • Nursing Service Philosophy.
5. Data Integrity • Protection from tampering 1.7. Use and monitoring of standardized abbreviations.Quality Improvement Program and other Projects 1.9. Retention period of records (as prescribed by law and institutional policy) Standard III: Administrative Record The Nursing Services Department has established policies or protocol in keeping and maintaining its administrative record and defining the requirements for developing and maintaining policies and procedures. Procedures.Protection from loss and destruction and unauthorized access and use 1. title. Committees. Identification of charges in policy and procedures 2. Process and frequency of review and continued approval of policies and procedures 220.127.116.11.2. Staffing Pattern 1.4.10. Retention of obsolete policies and procedures 2. Nursing Services Department • 1. date of issue.3. symbols.4.2. Organization and Nursing Services Department Policies. Census of Patients and Diseases 1.1.12. Nursing and the Organization 1.7.3. Standards 1. Master Staffing Plan 1. Review and approval of all policies and procedures before implementation 2.Manuals of the Organization • Quality System • Infection Control • Emergency Preparedness • Employees’ Manual • Others 2. Staff Development Programs 1. authorized person) V. Measurable Elements 1. Control that only current policy and procedures are implemented 2. Budget Plan 1.5. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. procedure codes and definitions 1. There is a written policy or protocol in keeping and maintaining Nursing Services Department administrative records which include but are not limited on the following: 1.6.g.11. References originating outside the organization 2.4. Guidelines 1. Bed Capacity and Occupancy Rate 1.6.8. Tracking of policy and procedures in circulation (e. Standards on Quality Improvement Standard I: Leadership and Staff Education The Nursing Services Department has continuous quality improvement on patient and staff safety programs through monitoring and analyzing variation of data and undesirable trends of events.Minutes of Meeting. Measurable Elements .
Total parenteral nutrition 1.1. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. Nursing documentation 1. 3. and other relevant evidence – based information. body fluids and waste segregation/disposal) 1. (e. surveillance. Medication safety.2. There is an established reporting system on the quality and safety programs to governance.6. There is a training program for staff consistent with their role in quality improvement and patient safety program. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. Measurable Elements 1. Medication error 1.5. processes and results and data are aggregated.8. Standard III: Quality Monitoring. monitoring. Intravenous fluids 1. There is an evidence that information on quality improvement and patient and staff safety programs are communicated to staff on a regular basis through effective channels inclusive of progress on compliance. Analysis & Implementation The Nursing Services Department has established key indicators to monitor the clinical and managerial structure.1. Those in governance support and take action on recommendation for quality improvement and patient and staff safety programs based on the result of root cause analysis. reporting (needle stick injury.9. Clinical research 1. clinical standards. There is a clinical monitoring that exists but is not limited on the following: 1. Standard II: Quality Programs The Nursing Services Department has priority quality programs to reduce high volume.4. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. Infection control. high risk and problemprone processes. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment. Prevention and control measures aligned with International Patient Safety Goals. 4. guidelines. Surgical safety (sterilization/disinfection) 1. There is an existing plan and program to reduce the risk of community/hospital acquired infectious for patients and health care associated infections for staff. analyzed and transformed to useful information. 5. hand hygiene and barrier technique.3. 3.7. clinical pathway) 2. 2. scientific literature. (Isolation Procedure) . 6. There is an evidence that the quality improvement/processes and safety programs are approved by governance. Measurable Elements 1. Blood and blood products 1. implemented and monitored for consistent use and effectiveness.g.
g. This applies within an organization or across multiple organizations. level of medical.4. Emergency Kart contents) 2. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. psychological. 5. 4.1. if any 2. GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization.3. 6. scope and severity of the problems. information resources management. verifying.6. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. tested and implemented. Financial budget 2. Staff expectations and satisfaction 2. the patient’s condition on discharge. There is an evidence that the actions for improvement or changes are planned. Patient and family expectations and complaints. use. Clinical Pathways – is an agreed-upon treatment regime that includes elements of care. or spiritual and social care or service. and assessing the qualifications of a health care practitioner like the nursing personnel. Incident reports and sentinel events 2. and information services. or nursing care. Manpower utilization 2. There is an evidence that actions for improvement are appropriate to the care. Reports as required by law and regulation and those in governance 3. Availability of drugs and medical supplies essential to most patient needs (e. Credentialing – is the process of obtaining. The process determines if an individual can provide patient care services in or for a health care organization. the significant findings. information technology. and other specific . There is a managerial monitoring that exists but is not limited on the following: 2.7. There is an evidence data analysis and actions taken. sharing and disposal of data or information for effective and efficient operation of organization activities.2. There is a written available data to demonstrate that the improvements are effective and sustained. the procedures performed. Patient demographics and clinical diagnoses 2. the treatment rendered.8.5.2. It includes the role of management to produce and control the use of data and information in work activities. Communication Management – is the creation.
risks. . group or agency that have ultimate authority and responsibility for establishing policy. and alternatives of a medical procedure or treatment before the physician or other health care professional begins the procedure or treatment. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. laboratories and long term organizations. applicable licensure. competence. protocols. and rehabilitation. progress notes and discharge summary. Qualification is determined by the following: education. clinical paths or a combination of these. In-Service Education – is an organized education.” and “governing body. lists the strategy to meet those needs. physicians and other health care professionals involved in the care of patients. maintaining quality of care. treatment details. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. or process. This includes ambulatory care centers. such as assessment findings. care. habilitation. registration. Health care professionals are often licensed by a government agency or certified by a professional organization. medications). nurse.” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. treatment. or certification. The format of the plan in some organizations may be guided by specific policies and procedures. and documents the individual’s progress in meeting specified goals and objectives. Indicator – is a measure of the performance of functions. The plan of care may include prevention. dentist. Patient Record/Clinical Record – is a written account of a variety of patient health information. usually provided in the workplace.” “board of trustees. hospitals. Other names for this group include “board. over time.” “board of commissioners.” board of governors. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment. and his/her life expectancy is estimated to be within days or months. Informed Consent – is an agreement or permission accompanied by full information on the nature.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. and providing for organization management and planning. training. practice guidelines.instructions given to the patient or family (for example. experience. behavioral/mental health institutions. documents treatment goals and objectives. This includes a physician. law or regulation. Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. It is also known as a “health care institution. follow –up. Plan of Care – is a plan that identifies the patient’s care needs. systems. or allied health professionals. This record is created by nurses. Governance – refers to the individual(s). It is based on data gathered during patient assessment. home care organizations. outlines the criteria for ending intervention.
Coulter M (2004).Quality of Care – is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Gerhart. 3rd Edition Printed in USA 54321 Joint Commission International (2004). Metro Manila Robbins. REFERENCES Association of Nursing Service Administrators of Philippines. (2001) Standards of Nursing Services the Association of Nursing Service Administrators of the Philippines. treatment. Edition Printed in USA 54321 Joint Commission International (2004). Outcome Standards – Describes the basis level of care the patient can expect to receive. and Philippine Nurses Association. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). Inc. Accreditation Standards for Hospitals. Edition Printed in USA 54321 Noe. Fundamental of Human Resource Management. Safety – is the degree to which the risk of an intervention and risk in the care environment are reduced for a patient and other persons. Standard – is a statement that defines the performance expectations. McGraw-Hill Co. Standard of Nursing Practice – is an authoritative statements that describe the responsibilities for which nursing practitioners are accountable. including health care providers. Inc. . (1999). structures. S. Pearson Education South Asia PTE LTD. 7th Edition. The Administration of Hospital Nursing Services in Philippine Department of Health. Credentialing. Republic of the Philippines. New York Republic Act 9173 or The Philippine Nursing Act of 1991. and service. Management. Wright (2004). Hollenback. Human Resources for Hospitals. Inc. or process that must be in place for an organization to provide safe and high-quality care. Inc. 1st Edition Joint Commission International (2008).
Lippincott Williams & Wilkins .M (2004). J (2006). Guide to Nursing Management and Leadership. 5 th Edition.Rowland H & Rowland B (1980). Handbook. 7th Edition Weber. Aspen Publication Nursing Administration Tomey A. Nurse’s Handbook of Health Assessment.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.